Wednesday, February 20, 2013

The numbers matter!

We all know Obamacare is bringing some new changes in healthcare. This past year, the AMA gave an Obamacare presentation at a healthcare software conference that I attend every fall. Interestingly enough, the main takeaway from that presentation is that even they can't decipher and keep up with all the legal jargon that's included in Obama's ever changing healthcare plan.

This past week however, I managed to experience parts of the new healthcare plan first hand through changes in my own healthcare coverage which is employer based. I have to say these new changes are definitely going to put a kink in getting any healthcare claims paid correctly. Quite honestly, from a practical standpoint, I don't see how either side is ever going to manage just the portion that I experienced.

For the last several years, my employer has offered a Wellness Screening or health assessment at no cost. With the blood pressure check and labs it's like an annual visit at your primary care doctor. What's not to like, right?

A couple of years ago, they upped the ante a bit to offer an incentive to participate in the Wellness Screening. If you decided not to participate, your premiums would cost more each month.

This year they upped the stakes a lot more citing that it was a government mandated program. While our premiums have not changed, our deductible has doubled with one caveat that is dependent on the results of the Wellness Screening.

The initial Wellness Screening will take place this month to get a baseline of levels including BMI, Cholesterol, Triglycerides, and Fasting Glucose or Sugar. Additionally, any counseling based on those levels will be prescribed. In August, right before corporate year end, a second Wellness Screening will be done to evaluate any progress or regression.

Based on the progress from the August labs and adherence to counseling, employees will have an opportunity to deduct $100 off of their annual deductible. For instance, if you lower your BMI levels by 5%, you can reduce your deductible by $100 the following year. If your BMI does not decrease even though you attend regular counseling sessions, your deductible will increase from the previous year.

The initial premise of this kind of plan is that it divides healthcare costs fairly. In other words, why should a willfully healthy person foot the bill of a willfully unhealthy person. I must say it makes initial sense, however I personally can see where this can easily go awry with mismanagement over time to include discrimination against health conditions such as diabetes, asthma, and even cancer in certain situations.

The kernel of truth to take away from my own experience is that sooner or later knowing your numbers will matter in getting your claims paid. Not only will you need to know what is covered under your plan, but you'll need to know what your own cholesterol levels are so that you can argue when your deductible has been applied incorrectly! It's been hard enough for insurance companies to keep up with a straight deductible and it will be impossible for them to manage your policy based on your lab results.

No one can keep up with your lab results better than you. In the end, not keeping up with those numbers can cost you $100!

Friday, February 1, 2013

Give It Time!

So often I talk to people that have worked themselves up in a tizzy because they received one response from their insurance and another from their provider's office on a claims issue. While it is entirely possible to call back three times and get three different answers, often times the discrepancy in answers can be attributed to time lapses.

The typical time period for a provider to enter smaller charges into their system is two days. Surgeries and more complicated bills can take up to a month. Once charges are entered into the system, it takes an average of two to three days before the claim actually arrives at the insurance company's electronic claims system.

The usual time that it takes an insurance company to process a clean claims is 14-30 days.It takes 60-90 days at best for a claim to be reprocessed by the insurance company.

Most of the time patients will receive their explanation of benefits before the provider's office receives their copy along with any payment. This is true for the initial processing as well as claims that are reprocessed.

Depending on staffing and set up, it can take anywhere from a week to a month for a provider's office to post a payment or to post an insurance response to an account. The time period for a claim's issue to actually be reviewed and worked can range anywhere from a month to three months.

Because of these lapses in time, it's not uncommon for statements and insurance responses to cross in the mail. When this happens, a patient may get a statement for a claim that's already been reprocessed.

In order to be efficient at getting your claims issues resolved, and to keep your blood pressure in check, it pays to understand the common time lines that providers and insurance companies work on. This will help you determine if what you've received or have been told is up to date and the final answer.